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  • Mark S Cantieri

Recommendations for Outpatient Musculoskeletal and Pain Practice During the COVID-19 Pandemic


In this time of struggle and uncertainty, it is important to maintain our objective of helping our patients with impairments and disabilities. Recent events have led to the Centers for Disease Control and Prevention (CDC) recommending a reduction of the number of outpatient visits as well as rescheduling all non-elective procedures. The goal of these recommendations is to lower the exposure risk to “flatten of the curve,” as well as reduction of Personal Protective Equipment (PPE) utilization. While reduction in the ongoing spread of COVID-19 is the priority, we still have a duty to help those in need. We must focus on continuing to provide the best possible care to our patients any way we can while minimizing the strain on our hospital systems, which are already highly stressed. Below we have outlined our current suggestions for responsible continued patient care.


If and when possible, we recommend conducting patient care by telemedicine, whether by electronic HIPPA compliant portals, email or telephone. There are resources available to assist physicians in transitioning to electronic medicine including those found in the recent publication by U.S. Centers for Medicare & Medicaid Services (CMS)

( https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf ).


If the patient feels strongly about being evaluated in person, a shared decision-making model is recommended. Many patients with various pain and neurological etiologies can be managed utilizing telemedicine; whether this involves addressing questions or concerns, medication management, prescription of exercise and therapy programs and reviewing imaging or laboratory results. However, in managing musculoskeletal care, many of our patients may report worsening neurological deficits or acute musculoskeletal injury, which necessitates an in-person evaluation. Not doing so may lead to significant functional decline.


If a patient does require a procedure, we advise that they be performed in the office or an ambulatory center (ASC) to reduce hospital burden, as well as to minimize exposure to potentially infected patients and staff members. The decision to continue to offer procedures and in-person evaluations should be made by taking into account both the well-being of the patient and medical personnel.


Although there is no evidence to suggest corticosteroid injections result in a substantial

increase in risk of being infected with COVID-19, there is evidence noting a reduced immune response with corticosteroid administration. 1 Both oral and injectable corticosteroids may cause a decrease in immunity. In light of the potential deleterious effect this may have on the defense against COVID-19, physicians should disclose this risk to their patients.


Elderly patients and those that are immunocompromised are particularly at greater risk of infection. Increased vigilance in these populations is warranted. 2 As the CDC works to uncover more details on COVID-19, all known factors that increase the risk of infection should be taken into account. When circumstances allow, providers should triage their patients directly (whether in-person or over the phone) to prevent unnecessary visits to the emergency room or urgent care. Examples of this includes acute pain symptoms that may benefit from a medication adjustment or an in-office injection. We recommend against closing offices unless expressly instructed to do so by local government, as this eliminates an essential path of the patient care paradigm.


Summary of Recommendations to Outpatient Musculoskeletal and Pain Physicians:

  1. Continue to see patients when clinically necessary.

  2. Avoid blanket in-office and procedure cancellations, which can potentially lead to unnecessary patient suffering.

  3. Make use of telehealth services as appropriate to meet the needs of our patients.

  4. Prevent further emergency room overload and strain by providing acute services when possible.

  5. Reduce requirements for PPE for simple joint and spine procedures that have a very low risk of infection.

  6. Exercise caution with the use of corticosteroids, particularly in higher risk patients who may be immunocompromised.

As musculoskeletal and spine specialists, we aim to achieve functional improvement in patients with a variety of impairments and disabilities. We need to strike the balance between exposing patients and staff to the virus and providing treatment for our patients. Further, a balance is needed in caring for critical patients with COVID-19 while still being able to care for the community in need. There will still be patients that have serious medical conditions and require immediate care. When a procedure is deemed “elective and non-urgent” this does not necessarily mean that the patient can wait. Some “elective” procedures should be performed in order to prevent worsening of the condition and further decompensation of the patient. We recommend that consideration of pain level, suffering and potential for functional loss should be integrated into future governmental and societal procedure recommendations.


As always, treatment decisions need to be individualized on a case-by-case basis to identify the optimal approach for each patient. The climate created by COVID-19 is ever changing and with it specific treatment recommendations, however with a thoughtful approach we will be able to navigate the COVID-19 pandemic with the least disruption for our patient population.


Sincerely,


Gene Tekmyster, DO

Board-Certified in Physical Medicine & Rehabilitation and Sports Medicine


Assistant Professor - Keck School of Medicine of USC, Department of Clinical Orthopaedic Surgery

Team Physician - US Ski & Snowboard


Maxim Moradian, MD

Board-Certified in Physical Medicine & Rehabilitation, Sports Medicine, Pain Medicine, and Regenerative Medicine


David W. Lee, MD

Board-Certified in Physical Medicine & Rehabilitation, and Pain Medicine


Shounuck I Patel, DO, MMS

Board-Certified in Physical Medicine & Rehabilitation, and Sports Medicine

Clinical Assistant Professor - Western University of Health Sciences

Clinical Assistant Professor - Touro University College of Osteopathic Medicine


Gerard Malanga, MD

Board-Certified in Physical Medicine & Rehabilitation, Sports Medicine, and Pain Medicine

Assistant Professor - Rutgers University


Gary P Chimes, MD, PhD

Board-Certified in Physical Medicine & Rehabilitation, and Sports Medicine


Rahul Desai, MD

Board-Certified in Radiology

President - Interventional Orthobiologics Foundation


Jaspal Ricky Singh, MD

Board-Certified in Physical Medicine & Rehabilitation, Sports Medicine, and Pain Medicine

Vice Chair and Associate Professor - Weill Cornell Medicine, Department of Rehabilitation

Medicine


Prathap Jayaram, MD

Board-Certified in Physical Medicine & Rehabilitation, and Sports Medicine

Director of Regenerative Sports Medicine - Baylor College of Medicine

Assistant Professor - Baylor College of Medicine, Departments of Physical Medicine &

Rehabilitation, and Orthopedic Surgery


References:

1. Haynes BF, Fauci AS. The differential effect of in vivo hydrocortisone on the kinetics of

subpopulations of human peripheral blood thymus-derived lymphocytes. J Clin Invest 1978; 61:703.


2. Dixon WG, Abrahamowicz M, et al. Immediate and delayed impact of oral glucocorticoid therapy on risk of serious infection in older patients with rheumatoid arthritis: a nested case-control analysis. Ann Rheum Dis. 2012;71(7):1128.

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